NCC243515_FRO Submitted_20241113

FINANCIAL RESPONSIBILITY/OWNERSHIP FORM
SEDIMENTATION POLLUTION CONTROL ACT
No person may initiate any land-disturbing activity on one or more acres as covered by the Act and within the
corporate limits or the extraterritorial jurisdiction of the City of Burlington before this form and an acceptable
erosion and sedimentation control plan have been completed and approved by the City of Burlington's
Erosion Control Administrator. (Please type or print, if the question is not applicable or the e-mail and/or fax
information unavailable, place N/A in the space provided. Blank spaces and/or inaccurate information will be
considered incomplete and could result in a disapproved plan.)
Part A.
1. Project Name BPG-WHITES KENNEL
2. Location of land-disturbing activity: County ALAMANCE City or Township BURLINGTON (ETJ)
Highway/Street WHITES KENNEL ROAD Latitude 36.0474 N Longitude 79.4455 W
3. Approximate date land-disturbing activity will commence: 11/15/2024
4. Purpose of development(residential, commercial, industrial, institutional, etc.):INDUSTRIAL
5. Total acreage disturbed or uncovered (including off-site borrow and waste areas): 12.98 AC
6. Amount of fee enclosed: $1,225 . The application fee is $225 for disturbed areas
between 1.0 and 2.0 acres, plus an additional $100 per acre (rounded up to the next acre) is assessed
without a ceiling amount(Example: a 9-acre application fee is $925).
7. Has an erosion and sediment control plan been filed? Yes No Enclosed X
8. Person to contact should erosion and sediment control issues arise during land-disturbing activity:
Name BLAIR PITTMAN, PE E-mail Address [e-mail]
Telephone [phone] Cell# Fax# [phone]
9. Landowner(s)of Record (attach accompanied page to list additional owners):
BPG BURLINGTON 1 LLC, A DELAWARE LLC
Name Telephone Fax Number
1540 GENESSEE ST
Current Mailing Address Current Street Address
KANSAS CITY MO 64102
City State Zip City State Zip
10. Deed Book No. 463 8 Page No. /D) 03 Provide a copy of the most current deed.
11. Tax Map No. 12 Block 5B Lot No. 42&60
12. Parcel ID 120421 & 120420 GPIN (State ID)8864-86-2173&8664-85-6718
Part B.
1. Person(s) or firm(s) who is financially responsible for the land-disturbing activity (Provide a
comprehensive list of all responsible parties on an attached sheet):
BOBBITT CONSTRUCTION, INC. [e-mail]
Name E-mail Address
2400 WESTON PARKWAY 2400 WESTON PARKWAY
Current Mailing Address Current Street Address
CARY NC 27513 CARY NC 27513
City State Zip City State Zip
Telephone [phone] Fax Number 919-851-1982

2. (a) If the Financially Responsible Party is not a resident of North Carolina, give name and street address
of the designated North Carolina Agent:
Name E-mail Address
Current Mailing Address Current Street Address
City State Zip City State Zip
Telephone Fax Number
(b) If the Financially Responsible Party is a Partnership or other person engaging in business under an
assumed name, attach a copy of the Certificate of Assumed Name. If the Financially Responsible
Party is a Corporation, give name and street address of the Registered Agent:
CT Corp. (Jessica Gomes) iessica.gomes(cr�wolterskluwer.com
Name of Registered Agent E-mail Address
160 Mine Lake Ct Ste 200
Current Mailing Address Current Street Address
Raleigh NC 27615
City State Zip City State Zip
Telephone [phone] Fax Number
The above information is true and correct to the best of my knowledge and belief and was provided
by me under oath (This form must be signed by the Financially Responsible Person if an individual
or his attorney-in-fact, or if not an individual, by an officer, director, partner, or registered agent with
the authority to execute instruments for the Financially Responsible Person). I agree to provide
corrected information should there be any change in the information provided herein.
Ty e or print name Title or Authority
Si nature Date
I, la ►�radtecj , a Notary Public of the County of 7 hfi.nS+nn
State of North Carolina, hereby certify that 12.T sfrn.1-1-� appeared
personally before me this day and being duly sworn acknowledged that the above form was
executed by him.
Witness my hand and notarial seal, this a 5- day of x,-fvbtor , 20 . -I
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